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Fundamentals of Law for Health Informatics and Information Management > Chapter 18 - Corporate Compliance > Flashcards

Chapter 18 - Corporate Compliance Flashcards

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1
Q

corporate compliance

A

a company’s adherence to the laws and regulations passed by official regulating bodies as well as general principles of ethical conduct

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2
Q

Health Care and Fraud Abuse Control (HCFAC)

A

a program designed to coordinate federal, state and local law enforcement activities with respect to health care fraud and abuse

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3
Q

National Health Care Anti-Fraud Association

A

a leading national organization focused exclusively on the fight against health care fraud

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4
Q

improper payment

A

Any payment that should not have been made or that was made in an incorrect amount (including overpayments and underpayments)

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5
Q

healthcare abuse

A

provider, supplier, or practitioner practices that are inconsistent with accepted sound fiscal, business, or medical practices

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6
Q

healthcare waste

A

overutilization or underutilization of services and misuse of resources in a healthcare context

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7
Q

solvency

A

the possession of assets in excess of liabilities; ability to pay one’s debts

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8
Q

upcoding

A

fraudulent medical billing in which a hospital bills the patient using a CPT code for a more expensive service than was performed

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9
Q

unbundling

A

(1) market or charge for (items or services) separately rather than as part of a package
(2) split (a company or conglomerate) into its constituent businesses, especially before selling them off.

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10
Q

conglomerate

A

(1) a number of different things or parts that are put or grouped together to form a whole but remain distinct entities
(2) a combination of multiple business entities operating in entirely different industries under one corporate group, usually involving a parent company and many subsidiaries

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11
Q

physician self-referral

A

the fraudulent practice of a physician referring a patient to a medical facility in which he has a financial interest

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12
Q

Stark Law

A

a set of United States federal laws that prohibit physician self-referral, specifically a referral by a physician of a Medicare or Medicaid patient to an entity for the provision of designated health services if the physician has a financial relationship with that entity
also known as the Federal Physician Self-Referral Statute

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13
Q

False Claims Act

A

an American federal law that imposes liability on persons and companies who defraud governmental programs

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14
Q

preponderance

A

the quality or fact of being greater in number, quantity, or importance

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15
Q

whistleblower

A

a person, usually an employee, who exposes information or activity within a private, public, or government organization that is deemed illegal, illicit, unsafe, fraud, or abuse of taxpayer funds

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16
Q

writ of qui tam

A

a writ through which private individuals who assist a prosecution can receive for themselves all or part of the damages or financial penalties recovered by the government as a result of the prosecution

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17
Q

qui tam relator

A

another word for a whistleblower who files a qui tam lawsuit

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18
Q

false claim

A

an attempt to get the government to pay money to anyone that was not intended to benefit; it involves lying either through misleading information or intentional omission of important information

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19
Q

knowing standard

A

a standard used in determining criminal liability in false claims; it refers to the fact that the person must have knowingly submitted a false claim either through knowing it was false, acting in reckless disregard of the truth, or acting in deliberate ignorance of the truth

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20
Q

Fraud Enforcement and Recovery Act of 2009 (FERA)

A

a federal law that enhanced criminal enforcement of federal fraud laws, especially regarding financial institutions, mortgage fraud, and securities fraud or commodities fraud

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21
Q

Federal Anti-Kickback Statute (AKS)

A

a federal law that prohibits knowingly and willfully offering, paying, soliciting, or receiving remuneration, directly or indirectly, in order to induce business for which payment may be made under any federal healthcare program

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22
Q

kickback

A

a payment made to someone who has facilitated a transaction or appointment, especially illicitly

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23
Q

remuneration

A

money paid for work or a service

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24
Q

induce

A

(1) to move by persuasion or influence
(2) to cause the formation of
(3) to determine by induction, specifically: to infer from particulars

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25
Q

particular proposition

A

(logic) a proposition that asserts something about some (but not all) members of a class

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26
Q

inductive reasoning

A

a method of reasoning in which a body of observations is synthesized to come up with a general principle

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27
Q

induction (people)

A

(1) the action or process of inducting someone to a position or organization
(2) the process or action of bringing about or giving rise to something
(3) the inference of a general law from particular instances

28
Q

solicitation

A

(1) the act of asking for or trying to obtain something from someone
(2) the act of accosting someone and offering one’s or someone else’s services as a prostitute

29
Q

accost (verb)

A

to approach and speak to (someone) in an often challenging or aggressive way

30
Q

“safe harbor” regulations

A

a federal law that describes various payment and business practices that, although they potentially implicate the federal anti-kickback statute, are not treated as offenses under the statute

31
Q

implicate

A

(1) to bring into intimate or incriminating connection
(2) to involve in the nature or operation of something
(3) to involve as a consequence, corollary, or natural inference

32
Q

corollary

A

(1) a proposition inferred immediately from a proved proposition with little or no additional proof
(2) something that naturally follows
(3) something that incidentally or naturally accompanies or parallels

33
Q

incidental

A

(1) being likely to ensue as a chance or minor consequence

(2) occurring merely by chance or without intention or calculation

34
Q

inference

A

a conclusion or opinion that is formed because of known facts or evidence

35
Q

artifice

A

(1) clever or artful skill: INGENUITY
(2) an ingenious device or expedient
(3) an artful stratagem: TRICK
(4) false or insincere behavior

36
Q

ingenuity

A

(1) skill or cleverness in devising or combining

(2) cleverness or aptness of design or contrivance

37
Q

apt

A

(1) unusually fitted or qualified: READY
(2) having a tendency : LIKELY
(3) ordinarily disposed : INCLINED
(4) suited to a purpose, especially: on point (e.g. an apt quotation)
(5) keenly intelligent and responsive

38
Q

contrivance

A

(1) a thing contrived, especially: a mechanical device

(2) an artificial arrangement or development

39
Q

contrive

A

(1) devise, plan
(2) to form or create in an artistic or ingenious manner
(3) to bring about by stratagem or with difficulty: manage

40
Q

stratagem

A

(1) an artifice or trick in war for deceiving and outwitting the enemy
(2) a cleverly contrived trick or scheme for gaining an end
(3) skill in ruses or trickery

41
Q

ruse

A

a wily subterfuge

42
Q

wily

A

full of wiles

a wile is a trick or stratagem intended to ensnare or deceive

43
Q

subterfuge

A

(1) deception by artifice or stratagem in order to conceal, escape, or evade
(2) a deceptive device or stratagem

44
Q

Deficit Reduction Act of 2005

A

a federal law that mandates compliance programs for those institutions receiving or making $5 million or more annually in Medicaid payments. The DRA’s False Claims Act Amendment is intended to reduce the amount of fraud, waste, and abuse in state and federal health care programs through employee education about the federal False Claims Act, state false claims acts, civil and criminal penalties, and protections from retaliation for those employees who report wrongdoings, misconduct, or violations of laws and regulations in good faith.

45
Q

OIG’s List of Excluded Individuals/Entities

A

also called the OIG Exclusion List
a list of people and organizations currently excluded from participation in Medicare, Medicaid, and all other federal healthcare programs
(OIG stands for Office of Inspector General)

46
Q

convoluted

A

(especially of an argument, story, or sentence) extremely complex and difficult to follow
(technical) intricately folded, twisted, or coiled

47
Q

Health Care Fraud Prevention and Enforcement Action Team (HEAT)

A

A joint HHS and Department of Justice (DOJ) initiative to combat Medicare and Medicaid fraud; it involves using real-time data analysis to investigate healthcare fraud cases.

48
Q

“pay and chase” approach

A

the attempt to recover funds after they have been paid, typically as a result of a fraudulent claim

49
Q

Fraud Prevention System (FPS)

A

state-of-the-art predictive analytics technology used to prevent fraud; it is used by the Centers for Medicare & Medicaid Services (CMS)

50
Q

Comprehensive Error Rate Testing (CERT)

A

a CMS program designed to measure the number of improper payments filed by a hospital by reviewing a sample of the claims

51
Q

Medicare Administrative Contractor (MAC)

A

a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries

52
Q

Zone Program Integrity Contractors (ZPICs)

A

companies responsible for identifying and investigating potential fraud in specific parts of Medicare

53
Q

Recovery Audit Contractors (RACs)

A

companies that identify and correct improper Medicare payments through the efficient detection and collection of overpayments made on claims of healthcare services provided to Medicare beneficiaries AND the identification of underpayments to providers so that CMS can implement actions that will prevent future improper payments

54
Q

Medicaid Integrity Contractors (MICs)

A

entities with which CMS has contracted to conduct post-payment audits of Medicaid providers

55
Q

National Benefit Integrity (NBI) Medicare Drug Integrity Contractor (MEDIC)
NBI MEDIC

A

a program that investigates fraud, waste, and abuse in the Medicare Parts C and D programs

56
Q

Supplemental Medical Review Contractor (SMRC)

A

a company charged with performing, and or providing support for, a variety of tasks aimed at lowering improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs

57
Q

culpable

A

deserving condemnation or blame

58
Q

corporate integrity agreement (CIA)

A

a document outlining the obligations that a company involved in health care in the United States makes with a federal government agency or a state government as part of a civil settlement

59
Q

settlement (law)

A

a resolution between disputing parties about a legal case, reached either before or after court action begins

60
Q

advisory opinion

A

The opinion of a judge, a court, or a law official, such as an attorney general, upon a question of law raised by a public official or legislative body. Advisory opinions adjudicate nothing and are not binding, though courts sometimes cite them as evidence of the law.
Federal courts in the United States will not issue advisory opinions, but such opinions are issued occasionally by a few state courts and routinely by the attorneys general of the various states upon the request of the governor, legislators, or other state officials.

61
Q

beneficiary inducement statute

A

a law that prohibits an individual or entity from providing remuneration to patients who are eligible for Medicare or Medicaid benefits if that individual or entity knows (or should know) that doing so is likely to influence the patient’s decision to order or receive items or services from a particular provider

62
Q

inducement

A

(1) a motive or consideration that leads one to action or to additional or more effective actions
(2) matter presented by way of introduction or background to explain the principal allegations of a legal cause, plea, or defense

63
Q

Provider Self-Disclosure Protocol

A

a federal program that gives providers the opportunity to avoid the costs and disruptions associated with a federal investigation and civil or administrative litigation by voluntarily disclosing self-discovered evidence of potential fraud

64
Q

corporate compliance program

A

an internal set of policies, processes, and procedures that an organization implements to help it act ethically and lawfully

65
Q

Two-Midnight Rule

A

A rule for paying Medicare claims:
Inpatient admissions would generally be payable under Part A if the admitting practitioner expected the patient to require a hospital stay that crossed two midnights and the medical record supported that reasonable expectation.
Medicare Part A payment was generally not appropriate for hospital stays expected to last less than two midnights. Cases involving a procedure identified on the inpatient-only list or that were identified as “rare and unusual exception” to the Two-Midnight benchmark by CMS were exceptions to this general rule and were deemed to be appropriate for Medicare Part A payment.

66
Q

four parts of Medicare

A

There are four parts of Medicare: Part A, Part B, Part C, and Part D.
Part A provides inpatient/hospital coverage.
Part B provides outpatient/medical coverage.
Part C offers an alternate way to receive your Medicare benefits (see below for more information).
Part D provides prescription drug coverage.

67
Q

Emergency Medical Treatment and Active Labor Act (EMTALA)

A

a federal law that requires anyone coming to almost any emergency department to be stabilized and treated, regardless of their insurance status or ability to pay

Fundamentals of Law for Health Informatics and Information Management (17 decks)

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